Page 147 - IC23 life insurance application

44 THE GAZETTE OF INDIA : EXTRAORDINARY [PART III—SEC. 4]

Annexure-I

Portability Form
PART-I
1) Name of the Policyholder / insured (s)

2) Date of Birth/Age

3) Address of the policyholder/insured
4) Details of existing insurer

i. Name of the product
ii. Sum Insured

iii. Cumulative Bonus

iv. Add-ons/riders taken
v. Policy number

5) Details of the proposed insurance

i. Name of the product proposed/intend to take
ii. Sum Insured Proposed

iii. Whether Cumulative Bonus to be converted to
an enhanced sum insured
6) Reason(s) for portability

7) No. of family member to be included in the policy to
be ported.

Enclosure: Photocopy of the existing policy documents
Date: Signature of the policyholder

PART–II
1. Whether the PED exclusions / time bound exclusion have longer exclusion period than the existing
policy: (Please indicate Yes / NO):

2. If yes, please give written consent to the declaration below:
“I am aware that the waiting period for the following disease(s)/treatment(s) is ….. Days/years more than the
previous policy terms. I hereby agree to observe the additional waiting period for the following
disease(s)/treatment(s)

Signature of the policyholder

Schedule-II
Administration of Health plus Life Combi Products
1. The product of this class shall be named as ‘Health plus Life Combi Products’ referred as ‘Combi
Products’ hereinafter in this schedule.

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